Understanding, Contextualizing, and Addressing PrEP Stigma to Enhance PrEP Implementation

Understanding PrEP misconceptions and their impact on PrEP initiation and use among pregnant and lactating women in Malawi

Mother-to-child transmission (MTCT) of HIV remains a challenge in Eastern and Southern Africa. Oral pre-exposure prophylaxis (PrEP) is a powerful tool to reduce MTCT, but women face barriers to effective use including those related to inaccurate comprehension of PrEP To understand women's misconceptions about PrEP and their potential impact on PrEP use, we conducted interviews with 33 pregnant and lactating women in Malawi using PrEP, and ten PrEP counselors and clinicians. The results indicate that, although pregnant women generally understood PrEP's features and functions, many held misconceptions that persisted over the course of their PrEP use and impacted their perceptions and use of the medication. Some women erroneously believed that PrEP could treat and prevent sexually transmitted infections other than HIV, which motivated some to keep taking PrEP while motivating others to stop using PrEP once their STI had resolved. Some were confused about PrEP's function, with some believing it was the same as antiretroviral therapy for HIV treatment, and others believing that PrEP could be used for overall enhancement of health. Rarer misconceptions included fears that PrEP was connected to satanic practices, could cause cancer, or was solely for individuals engaged in sex work. These misconceptions stemmed from a mix of prior knowledge, societal influences, and miscommunications during counseling sessions. Ensuring accurate knowledge and addressing common misconceptions head-on is crucial to promote continued PrEP use among women. Both clinic- and community-based communication efforts with a particular focus on the difference between PrEP, STI treatments, and ART are needed.

Exploring Willingness to Use Long-Acting Injectable PrEP Among Sexual and Gender Minoritized People Accessing Pharmacies

This mixed-methods study explored willingness to use long-acting injectable pre-exposure prophylaxis (LAI-PrEP) among a pharmacy-based sample of men, including sexual and gender minoritized (SGM) individuals. We conducted qualitative interviews (n = 10) with HIV-negative Black men, including Black SGM individuals, and surveys (n = 103) across three study phases with men recruited from community pharmacies in Atlanta, Georgia. Interviews explored perceived benefits and concerns related to LAI-PrEP; surveys assessed willingness and related reasons. Thematic analysis was used for interview transcripts, and descriptive statistics summarized survey responses. Participants mentioned benefits such as improved adherence and reduced stigma, but also noted concerns about medical mistrust and fear of needles. Willingness was higher in the transitional pilot phase than in the pilot phase, where concerns about side effects and comfort were more common. Findings highlight the need for tailored LAI-PrEP strategies that address barriers among Black SGM populations and promote equitable HIV prevention.

Multilevel Intervention to Support Tailored and Responsive HIV Pre-Exposure Prophylaxis Care in Rural North Carolina: Protocol for a Randomized Controlled Trial

BACKGROUND

While access to pre-exposure prophylaxis (PrEP) is an important tool for reducing HIV incidence in the United States, disparities in uptake by race, sex, socioeconomic status, and geography persist. In 2018, the US South accounted for more than half of all new HIV diagnoses but only one-third of PrEP users. PrEP use in North Carolina (NC) similarly lags, with uptake being the lowest among young, sexual and gender minority populations, who account for nearly two-thirds of the state's incident infections. The PrEP-to-need ratio, a metric of PrEP equity that measures PrEP uptake relative to new HIV diagnoses, highlights disparities in PrEP uptake among specific demographic groups such as women and Black, Hispanic, and Southern people, indicating that these groups are underserved relative to their epidemic need. Despite behavioral risk overlap of incident sexually transmitted infections (STIs) and HIV, in NC, PrEP is only offered at a few primarily urban health department-affiliated STI clinics. The lack of robust health care infrastructure in these areas presents challenges for HIV prevention services.

OBJECTIVE

This protocol describes a randomized controlled trial of a multilevel PrEP intervention recruiting from rural and periurban STI clinics.

METHODS

This trial aims to enroll up to 336 participants and randomly assign them 1:1 to either the intervention or control group. The intervention consists of access to a digital health app, linkage to a remote PrEP navigator, and the option of referral to telehealth-based PrEP services. Persons randomly assigned to the control condition will receive an enhanced standard of care, including access to a limited version of the digital health app. All participants will be followed up on quarterly for at least 3 months. The primary outcome is the initiation of PrEP within 3 months of an index STI clinic visit; secondary outcomes evaluate PrEP care engagement and adherence, incident HIV and bacterial STI infections, PrEP stigma, and cost-effectiveness. Binary outcome analyses will estimate the proportion of participants achieving an event (eg, PrEP uptake) in each arm and a probability difference and the corresponding 95% CI to compare the intervention versus control arm at each time point. Continuous end points will use nonparametric Wilcoxon rank sum tests comparing the intervention and control groups.

RESULTS

Enrollment opened on August 31, 2023, at 15 health departments in NC and subsequently expanded to 21 facilities in 20 counties by July 2024. Completion of the enrollment and data collection phases is expected by May 2025. Results will be published thereafter.

CONCLUSIONS

This study directly addresses multiple barriers to PrEP use in rural and periurban areas of the Southeastern United States and can inform policy and programming that seek to expand PrEP access and promote use in underserved communities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05984030; https://clinicaltrials.gov/study/NCT05984030.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/68085.

Factors Associated with PrEP Stigma Among Gay, Bisexual, and Other Men Who Have Sex with Men (gbMSM): A Systematic Review

Gay, bisexual, and other men who have sex with men (gbMSM) are disproportionately affected by HIV. While pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition, uptake of PrEP among gbMSM is low, which may in part be due to stigma associated with PrEP use. This systematic review aimed to explore experiences of PrEP stigma and to identify factors associated with this. Four databases were searched for papers including terms relating to (i) gbMSM, (ii) PrEP, and (iii) stigma, with narrative synthesis used to analyze results. After screening, 70 studies were included in the final analysis. Experiences of PrEP stigma were found to be characterized by a number of stereotypes and came from a range of sources. Five categories of factors were associated with stigma: (i) healthcare-related factors, (ii) cultural and contextual factors, (iii) sociodemographic factors, (iv) peer-discussion, and (v) psychosocial factors. These findings suggest that stigma can be a common experience for gbMSM. However, some are more at risk than others. Interventions aimed at reducing PrEP stigma may be useful in increasing uptake.

HIV pre-exposure prophylaxis re-initiation among men who have sex with men: a multi-center cohort study in China

Background Data on persistent use of HIV pre-exposure prophylaxis (PrEP) is limited among Chinese men who have sex with men (MSM). This study aimed to explore factors associated with the re-initiation of PrEP among Chinese MSM from a longitudinal PrEP demonstration trial. Methods A multi-center cohort study was conducted in Guangzhou and Wuhan, China (September 2021-2024), providing 1134 MSM participants with a 12-month dosage of tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) as oral PrEP. Following the trial, a subgroup of participants were invited to complete a 3-month post-trial follow-up survey. These participants were categorized on the basis of self-reported PrEP use patterns into (1) continued PrEP use, (2) discontinued without re-initiation, and (3) re-initiated after discontinuation. Log-binomial regression models were used to assess factors associated with PrEP re-initiation. Results Out of 408 participants who completed the 3-month post-trial follow-up survey, 70.1% (n =286/408) reported discontinuing PrEP, and 50.7% (n =145/286) of those who discontinued subsequently re-initiated PrEP. Participants who had concurrent sexual partnerships (adjusted risk ratio [aRR]=1.47, 95% CI: 1.11-1.96), used drugs during sex (aRR=1.34, 95% CI: 1.09-1.65), or lived alone (aRR=1.29, 95% CI: 1.03-1.61) were more likely to re-initiate PrEP. The Likert scale analysis indicated that perceived partner influence, specifically the expectation of condomless sex, played a significant role in re-initiation decisions (P =0.03). Conclusion Individuals engaging in higher-risk behaviors are more likely to re-initiate PrEP, highlighting the dynamic nature of risk perception. Future interventions should focus on promoting both re-initiation and consistent condom use, emphasizing partner-related dynamics and substance use as key factors in PrEP decisions among MSM.

Early Implementation of Long-Acting Injectable Cabotegravir for HIV Prevention in a Safety Net Hospital-based Primary Care Center in U.S. South

BACKGROUND

Long-acting injectable cabotegravir (CAB-LA), approved in 2021, is a more effective HIV prevention method than daily oral PrEP. CAB-LA expansion addresses key HIV prevention gaps, especially in the Southern United States (U.S.), to support national Ending the HIV Epidemic (EHE) goals. However, complex implementation requirements hinder CAB-LA expansion, highlighting the need for real-world data to guide effective and equitable scale-up.

OBJECTIVE

Describe the implementation and early outcomes of implementing CAB-LA in a large safety-net primary care center in the Southern U.S.

DESIGN

We described the integration of CAB-LA into an existing oral PrEP program. We manually abstracted individual sociodemographic and clinical data. We developed a CAB-LA care continuum and reported early outcomes among CAB-LA initiators.

PARTICIPANTS

Individuals referred to the CAB-LA program from 12/1/2022 to 8/1/2023, with outcomes assessed through 12/1/2023.

MAIN MEASURES

Development of a CAB-LA care continuum from linkage, eligibility assessment, program enrollment, initiation, and persistence. We reported the sociodemographic and clinical characteristics of individuals referred for and initiated on CAB-LA, the total number and timing of injections administered, self-reported adverse events, CAB-LA discontinuations, and HIV seroconversions.

KEY RESULTS

Integration of CAB-LA into an existing oral PrEP program required multidisciplinary team adaptation, protocol development for drug procurement and care coordination, and adapting an existing population health registry to the CAB-LA workflow to monitor and track individuals. Of 221 referred individuals, 77 (35%) initiated CAB-LA. Initiation barriers included program intake scheduling delays (29%), individuals declining CAB-LA (19%), and delayed medication procurement (16%). Among CAB-LA initiators, 275 injections were administered, 94% were administered on time, six individuals (8%) reported adverse effects, and eight (10%) discontinued CAB-LA. No HIV seroconversions occurred.

CONCLUSIONS

We successfully implemented a CAB-LA PrEP program in a safety-net primary care center in the U.S. South, using an approach designed to address structural barriers to PrEP uptake and persistence.

Understanding the PrEP Care Continuum for Adults: Health Care Providers' Perspectives on Barriers, Facilitators, and Missed Opportunities

Pre-exposure prophylaxis (PrEP) is an effective strategy in reducing HIV transmission, yet its uptake remains suboptimal. Health care providers play a vital role in facilitating PrEP access and care. This qualitative study explores health care providers' perspectives on the oral PrEP care continuum for adults, emphasizing barriers, facilitators, and missed opportunities in PrEP implementation. Drawing on interviews with 18 primary care providers in New York State, our research investigates multi-level factors influencing PrEP awareness, initiation, and management. Findings reveal significant barriers at the patient level, such as low awareness, stigma, and misconceptions about HIV risk. Provider-level challenges include knowledge gaps, discomfort in discussing sexual health, and logistical constraints. Structural factors such as insufficient infrastructure and high costs impede consistent PrEP management. Facilitators identified include proactive provider-patient communication, educational resources, and workflow integration strategies. Subgroup analyses highlight variations in attitudes based on provider demographics and experience. Younger and female providers are more proactive in discussing PrEP, while older and male providers often perceive it as less relevant. Nurses emphasize patient education and trust-building, contrasting with physicians' focus on logistical challenges. Providers experienced in prescribing PrEP view it as a valuable prevention tool, while nonprescribers report hesitancy and limited familiarity. Discrepancies in patient-perceived versus actual HIV risk, as well as provider assumptions about patient candidacy for PrEP, underscore the need for routine, stigma-free discussions about HIV prevention. This study emphasizes the importance of targeted provider training, system-level support, and inclusive policies to enhance PrEP uptake. Addressing these barriers and leveraging facilitators can advance public health efforts, fostering equitable and effective HIV prevention strategies.

Health System Factors Influencing the Integration of Pre-Exposure Prophylaxis into Antenatal and Postnatal Clinic Services in Cape Town, South Africa

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is an effective and safe option to prevent HIV acquisition and vertical HIV transmission in pregnant and breastfeeding women. Understanding health system factors influencing the integration of PrEP into care for pregnant and breastfeeding women is key to increasing access. We explored managers' and health care workers' (HCWs) experiences with integrating PrEP into antenatal care and postnatal care services in primary health care clinics in Cape Town, South Africa.

METHODS

This exploratory qualitative study used codebook thematic analysis, where HCWs were purposively, heterogeneously sampled from an implementation science study. Semistructured individual interviews were conducted with 9 managerial-level staff, and 3 focus group discussions were conducted with HCWs (nurses, midwives, and HIV counselors) providing PrEP (6-7 HCWs per group) between November 2022 and January 2023 (N=28). Interview guides covered health system facilitators, barriers, and recommendations. The Health Systems Dynamics framework guided data analysis and presentation of results.

RESULTS

PrEP integration into antenatal care services was described as acceptable and feasible; however, changes to HIV testing policy and indicators in breastfeeding women are needed to integrate PrEP into postnatal clinics, together with identification of mother and baby as a dyad in visits. Results showed that supportive policies facilitated wider, simplified PrEP provision. The availability and accessibility of prescribing nurses and lay HIV counselors, PrEP (both within facilities and in communities), and information about PrEP for implementers and pregnant and breastfeeding women will be pivotal to facilitating integration.

CONCLUSION

Facilitators for PrEP integration include task-shifting PrEP education and identification of women for PrEP initiation to HIV counselors, changes to national guidelines defining who can prescribe PrEP, revision and integration of PrEP training for HCWs, community-level interventions for PrEP demand creation and stigma reduction, and provision of differentiated PrEP delivery options.

PrEPárate: Evaluation of a Community-Driven PrEP Social Marketing Intervention Tailored to Latino/a/x Individuals

Latino/a/x sexual minority men (SMM) and transgender women remain disproportionately impacted by HIV, with higher HIV incidence and lower uptake of pre-exposure prophylaxis (PrEP) than their non-Hispanic White peers. Disparities in PrEP uptake among Latino/a/x populations have been found to be due to structural, social, and personal barriers. Social marketing interventions have been shown to effectively address barriers and increase PrEP uptake in other populations, and thus offer potential as a tool to increase PrEP uptake for Latino/a/x populations. The PrEPárate campaign was developed through community based participatory research and ran from April to September 2022 in Cook County, Illinois. We conducted a mixed methods evaluation through surveys (N = 515) and semi-structured interviews with survey participants and community partners (N = 14). We examined cross-sectional associations of campaign exposure with PrEP awareness and uptake in adjusted multivariable regression models. We used rapid qualitative methods to analyze interviews and assess implementation outcomes following the RE-AIM framework. The campaign reached over 118,000 people on social media, with additional reach over public transit and local events. PrEPárate exposure was associated with increased PrEP awareness (aOR = 5.23; 95% CI [2.58, 10.63]) and PrEP uptake (aOR = 1.69; 95% CI [1.09, 2.62]). Survey respondents expressed that the campaign name, visuals, ambassadors, and distribution were effective in engaging the target audience. Community partners felt the campaign was implemented with fidelity to the original vision and identified future directions for PrEPárate. Social marketing campaigns, anchored in community engagement, may be an effective strategy to increase PrEP awareness and uptake among underserved Latino/a/x populations.

Intersectionality in Health Communication: How Health Communication Influences the Association Between Intersectional Discrimination and Health Information Seeking

With an intersectional orientation, we examine associations between discrimination, health communication, and information-seeking intention about HIV prevention in the context of pre-exposure prophylaxis (PrEP) among cisgender women through an online survey (N = 341). We elaborate on the idea that intersectional discrimination is a social determinant of health by considering the context with differing power relations-day-to-day life and the healthcare field-based on Bourdieu's field theory, and explore moderating roles of health communication in this relationship according to the structural influence model of communication (SIM). The relationships between intersectional discrimination and intention show different patterns by the context in which intersectional experiences are considered, and the relationships are moderated differently by the mode of health communication. We discuss how to conduct intersectionality-informed health communication research without sacrificing intersectionality's foundational foci.

Enhancing daily oral PrEP adherence with digital communications: Protocol for a systematic review and meta-analysis

INTRODUCTION

Pre-exposure prophylaxis (PrEP) stands as an effective tool in preventing HIV transmission among individuals at risk of HIV infection. However, the effectiveness of daily oral PrEP is contingent on the adherence of its users, which can pose a challenge for many individuals. Various studies have explored different interventions aimed at bolstering PrEP adherence. One recurring type of intervention revolves around digital communication (e.g., SMS, mobile applications) to send reminders for PrEP usage. The objective of our systematic review and meta-analysis is to address the following research question: What is the effectiveness of digital communication interventions in enhancing daily oral PrEP adherence among individuals at a heightened risk of HIV infection? This paper presents our study protocol.

METHOD AND ANALYSIS

We will conduct searches across four health-related databases: Embase, PubMed, Web of Science, and PsycINFO. We will also explore other sources, including clinical trials registries and grey literature. Our search will be restricted to original randomized controlled trials published in English, French, and Spanish conducted since 2012, when PrEP was approved, to today. To ensure rigor, three reviewers will perform the systematic review and meta-analysis. This systematic review will adhere to the guidelines outlined in the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Our primary outcome of interest is proper daily oral PrEP adherence, which we will measure using association metrics (e.g., odds ratios).

DISCUSSION

This review will offer insights into the effectiveness of utilizing digital communication methods to assist individuals at risk of HIV in improving their PrEP adherence.

PROTOCOL REGISTRATION NUMBER

International Prospective Register for Systematic Reviews (PROSPERO) number CRD42023471269.

The Association between Social Support and Pre-Exposure Prophylaxis use among Sexual Minority Men in the United States: A Scoping Literature Review

Sexual minority men (SMM) are disproportionately affected by HIV. Although pre-exposure prophylaxis (PrEP) is an effective way of reducing HIV incidence, PrEP use has remained relatively low. Social support may be one effective factor in increasing PrEP use among SMM, but the association between social support and PrEP use/adherence is not well understood. The objective of this paper was to summarize the current literature on the association of social support and PrEP use among SMM in the United States. A systematic search was conducted using six different databases MEDLINE / PubMed, PsycINFO, Cochrane CENTRAL, Google Scholar, Embase, and Web of Science using terms established from keywords and medical subject headings (MeSH) terms before being adapted to each database. Data were extracted for key study factors (e.g., study population, geographic location, study design) and main findings. This search produced eleven articles: ten manuscripts and one conference abstract. Of these, two were randomized control trials, two were interventions, three were qualitative, and four were cross-sectional. The studies were widespread across the country, but most were in major metropolitan areas. From the articles included in this review, findings were inconsistent in the association between social support; some studies showed null findings, others that only certain sources of social support were significant, and others that there was a significant association between social support and PrEP use. This review highlights the complexity of the relationship between social support and PrEP use among SMM, indicating the need for further research to identify specific types and sources of support that effectively enhance PrEP uptake and adherence. Targeted interventions based on these insights could significantly reduce HIV incidence in the population.

Interest in and Willingness to Use PrEP: A Cross-Sectional Study of Individuals with Problematic Substance Use Residing in a High HIV Prevalence Jurisdiction

Although it is an effective HIV prevention method, pre-exposure prophylaxis (PrEP) is underutilized in the Southern US. Many people who use drugs (PWUD) have increased susceptibility to HIV which could be lessened by using PrEP. Potential barriers to PrEP use include lack of awareness of PrEP, low knowledge about HIV prevention, low self-efficacy for HIV prevention, inaccurate risk perceptions, and anticipated stigma. The current study examined predisposing, enabling, and reinforcing factors that may predict interest in PrEP. The purpose of the current study was to explore factors associated with interest in and willingness to use daily oral and long acting injectable PrEP among sexually active adult PWUD. The data were collected from adult participants (n = 270) residing in Harris County, TX, who self-reported problematic substance use and who reported oral, anal, or vaginal sex in the six months prior to completing the survey. The survey was distributed and completed online via Qualtrics Panels in March of 2022 and included measures of PrEP and HIV knowledge, PrEP stigma, sexual health self-efficacy, experiences of discrimination, health literacy, and medical mistrust. The majority of participants reported circumstances or behaviors that increased their susceptibility to HIV. Findings indicated that PrEP user stereotypes and PrEP anticipated disapproval by others were associated with interest in using daily oral PrEP and willingness to use long acting injectable PrEP. These results provide insight into reasons for low PrEP uptake among PWUD who live in a high HIV prevalence jurisdiction. Implications for HIV prevention intervention are discussed.

Associations Between PrEP Stigma, PrEP Confidence, and PrEP Adherence: Conditional Indirect Effects of Anticipated HIV Stigma

BACKGROUND

Research has linked stigma surrounding preexposure prophylaxis (PrEP) to poor HIV prevention outcomes, including PrEP adherence. However, there remains a limited understanding of the mechanisms through which PrEP stigma affects PrEP adherence, specifically among sexual and gender minority (SGM) youth. In this study, we aimed to investigate the indirect effect of PrEP stigma on PrEP adherence through PrEP confidence and the moderating role of anticipated HIV stigma.

METHODS

Participants included 235 SGM youth, assigned male sex at birth, aged 16-24, and self-reported HIV-negative, with an active PrEP prescription from the Prepared, Protected, emPowered randomized controlled trial. Participants were recruited from 9 clinics in the United States between 2019 and 2021. Using baseline data, we tested cross-sectional indirect and conditional indirect effects using the Statistical Package for the Social Sciences Process with confidence intervals and 2000 resamples.

RESULTS

We found significant indirect effects, suggesting that PrEP stigma was negatively associated with PrEP confidence, which in turn resulted in both monthly and weekly optimal PrEP adherence (Indirect effects: B = -0.11, Standard Error [SE] = 0.05, CI: [-0.244 to -0.032]; B = -0.09, SE = 0.04, CI: [-0.191 to -0.014], respectively). Anticipated HIV stigma moderated these indirect effects (B = -0.11, SE = 0.08, CI: [-0.315 to -0.001]; B = -0.09, SE = 0.06, CI: [-0.245 to -0.001], respectively), suggesting that the conditional indirect effects were significant at high but not low levels of anticipated HIV stigma.

CONCLUSION

Results suggest that SGM youth who are on PrEP anticipating HIV stigma experience a compounding effect of PrEP stigma on PrEP confidence, consequently leading to suboptimal adherence. Interventions addressing the intersectionality of PrEP and HIV stigmas and enhancing confidence could improve PrEP adherence, particularly among SGM youth.

Feasibility and assessment of a comprehensive emergency department-based intervention for patients at risk of HIV

Behavioral factors increase the risk of contracting HIV. A comprehensive prevention services (CPS) intervention includes risk assessment and referral for those with confirmed risk. This project sought to assess the feasibility of an emergency department (ED)-based CPS program. A prospective cross-sectional assessment was conducted from October, 2021 through May, 2023, at a single ED in Birmingham, Alabama. Either of two screening methods were subjected to HIV negative adults: 1) manual chief complaint review or 2) objective electronic medical record (EMR) query. Manual and EMR screening methods considered sexually transmitted infections (STIs) or a positive urine drug test (to observe for commonly injectable drugs) within 12 months of current ED visit. Identified patients were approached in the ED (manual review) or via phone (EMR alert). Persons confirmed at risk for HIV following engagement questionnaire completion were made aware of their risk and offered referral to local CPS clinics. Primary outcome was CPS linkage. Descriptive analysis was performed. Of 184 patients approached, 147 agreed to engagement (79.9%), 117 in-person and 30 via phone; 125 (85.1%) were confirmed at risk for HIV; majority were white (66.4%), male (63.2%), between the ages of 30 and 49 (64.8%), uninsured (78.4%), and without a primary care provider (93.6%). Sexual behavior was identified as a recent (within six months) risk factor in 97 (77.6%) patients. Injection drug use was identified as a recent (within six months) risk factor in 71 (56.8%) patients. Fifty-four (43.2%) expressed interest in obtaining CPS follow-up. To-date, ten patients (18.5%) have connected with a CPS counsellor via phone and five (9.3%) have had a subsequent follow-up appointment to discuss CPS with a medical provider. Thirty at-risk patients (24.0%) received ED-initiated buprenorphine/naloxone. Targeted screening tools can aid in the identification of persons at risk for HIV in the ED; further, subsequent engagement and CPS implementation amongst this cohort is feasible. CPS clinic linkage may be challenging however, a CPS definition inclusive of ED-initiated medication for opioid use disorder, may offer opportunity for increased uptake.

History of Rectal Product Use and Country of Residence Influence Preference for Rectal Microbicide Dosage Forms Among Young Sexual and Gender Minorities: A Multi-country Trial Comparing Placebo Douche, Suppository, and Insert Products

The DESIRE Study (MTN-035) explored product preference among three placebo rectal microbicide (RM) formulations, a rectal douche (RD), a suppository, and an insert, among 210 sexually active transgender people and men who have sex with men in five counties: the United States, Peru, Thailand, South Africa, and Malawi. Participants used each product prior to receptive anal sex (RAS) for 1 month, following a randomly assigned sequence, then selected their preferred product via computer assisted self-interview. In-depth interviews examined reasons for preference. We compared product preference and prior product use by country to explore whether geographic location and experience with the similar products impacted preference. A majority in the United States (56%) and Peru (58%) and nearly half in South Africa (48%) preferred the douche. Most in Malawi (59%) preferred the suppository, while half in Thailand (50%) and nearly half in South Africa (47%) preferred the insert. Participants who preferred the douche described it as quick and easy, already routinized, and serving a dual purpose of cleansing and protecting. Those who preferred the insert found it small, portable, discreet, with quick dissolution. Those who preferred the suppository found the size and shape acceptable and liked the added lubrication it provided. Experience with product use varied by country. Participants with RD experience were significantly more likely to prefer the douche (p = 0.03). Diversifying availability of multiple RM dosage forms can increase uptake and improve HIV prevention efforts globally.

A Study on Perceptions of Undetectable = Untransmittable Among Gay Men with Human Immunodeficiency Virus in the HIV Community on Twitter in Japan: An Exploratory Qualitative Study Using a Modified Grounded Theory Approach

This study explores the perceptions of the Undetectable = Untransmittable (U = U) campaign among gay men with HIV in Japan who are part of the HIV community on Twitter. We conducted detailed semistructured interviews with 12 participants using a modified grounded theory approach. The analysis resulted in 31 concepts, 5 subcategories, 9 categories, and 2 core categories. The relationship between categories and core categories was examined in conjunction with the transcriptions, yielding a comprehensive category map depicting the process of understanding U = U. The three main processes emerged: participants expressed "expectations for improvement," underwent stages of "understanding U = U," and encountered "dilemmas" in forming their opinions. There are two routes to "understanding U = U": Route 1 involved a frictionless understanding of U = U, and Route 2 involved difficulty in understanding the slogan. In both routes, participants experienced the dilemma of "but I still have HIV" and regarding its ease of use. These dilemmas and difficulties in understanding U = U affected their "expectations for improvement." Efforts to promote U = U in Japan must address challenges in public understanding and related dilemmas. This entails reformulating the U = U message in simpler terms, leveraging professional explanations, disseminating it to a broader audience, and incorporating ideas from individuals living with HIV to enhance the message.

"PrEPping" women's healthcare providers: motivational interviewing to support ending the HIV epidemic

In 2018, cisgender women accounted for nearly 20% of new HIV infections, with women of color disproportionately affected. HIV pre-exposure prophylaxis uptake, adherence, and persistence are paramount to ending the HIV epidemic, but current strategies to promote it have not improved uptake among women. Alternatively, pre-exposure prophylaxis marketing and implementation have traditionally targeted men who have sex with men and transwomen. Women feel most comfortable turning to their primary care and reproductive health providers for HIV and pre-exposure prophylaxis counseling, but prescribing is the lowest among these providers. Thus, reframing pre-exposure prophylaxis counseling and education strategies is crucial to better engage providers and patients. Motivational interviewing is a person-centered counseling style for eliciting behavior change. Providers use 4 core skills-open-ended questions, affirmation, reflective listening, and summarizing-to empower individuals for behavior change, such as pre-exposure prophylaxis use. Motivational interviewing is brief, individualized, and effective in increasing pre-exposure prophylaxis uptake, regardless of patients' readiness to change. Primary care and reproductive health providers can employ motivational interviewing approaches with pre-exposure prophylaxis counseling to increase uptake among cisgender women and end the HIV epidemic.

Psychiatry and Family Medicine Residents' Likelihood of Prescribing HIV Pre-exposure Prophylaxis to Patients With Mental Illness and HIV Vulnerability

BACKGROUND

People living with mental illness (PLMI) experience disproportionately high incidence of and vulnerability to HIV. Pre-exposure prophylaxis (PrEP) is an effective and safe HIV prevention method, but data regarding prescription to PLMI are lacking. Psychiatrists may serve as important points of access for PrEP prescription for PLMI.

METHODS

We conducted a vignette-based study of residents in psychiatry and family medicine (FM) to assess likelihood of prescribing PrEP and assumptions about the fictional patient. Participants were randomized to one of five vignettes in which the patients' psychiatric diagnosis was varied (schizophrenia on long-acting injectable or oral antipsychotic, bipolar disorder, major depression) or a control vignette without a psychiatric diagnosis.

RESULTS

A total of 439 residents participated. We found that high percentages of psychiatry (96.8%) and FM (97.4%) residents were aware of PrEP. High percentages of psychiatry (92.0%-98.1%) and FM (80.8%-100%) residents reported that PrEP was indicated for all patient conditions. Family medicine residents were more likely to prescribe PrEP to all experimental conditions than psychiatry residents. There was no difference in likelihood of prescribing to the control condition without a psychiatric diagnosis. The belief that PrEP prescription was out of scope of practice was greater among psychiatry residents.

CONCLUSIONS

A majority of psychiatry residents responded that PrEP was indicated for an array of patients with psychiatric diagnoses. However, psychiatry residents were broadly less likely to prescribe PrEP to patients with these diagnoses. The high percentage of psychiatry residents who reported that PrEP was indicated for all patients suggests that additional training is needed to facilitate PrEP prescription by psychiatrists.

Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis

BACKGROUND

Especially in high HIV prevalence contexts, such as Zambia, effective biomedical prevention tools are needed for priority populations (PPs), including key populations (KPs), who are at higher risk. HIV pre-exposure prophylaxis (PrEP) has been scaled up nationally in Zambia, but little is known about barriers to PrEP use among specific PPs to date.

METHODS

To understand barriers and facilitators to PrEP use in Zambia, we conducted a qualitative case study of PrEP services to PPs including sero-discordant couples (SDCs), female sex workers (FSWs), and men who have sex with men (MSM) in Livingstone. The study conducted in 2021 included in-depth interviews (n = 43) guided by the socio-ecological model, and focus group discussions (n = 4) with clinic and community-based providers and PrEP-eligible clients including users and non-users across PP groups. We used thematic analysis to analyze data using codes derived both deductively and inductively.

RESULTS

We found multilevel barriers and facilitators to PrEP use. Cross-cutting barriers shared across PP groups included amplifying effects of PrEP being mistaken for antiretroviral drugs used to treat HIV, including anticipated stigma, and concerns about side-effects based on both misinformation and experience. In addition, stigmatized identities, particularly that of MSM, served as a barrier to PrEP use. The fear of being mislabeled as having HIV was of greatest concern for FSWs. Facilitators to PrEP use primarily included the importance of confidential, KP-sensitive services, and the role of informed, supportive family, friends, and peers. Participants across all PP groups urged expanded education efforts to increase awareness of PrEP within the general population toward mitigating concerns of being mislabeled as living with HIV.

CONCLUSION

To our knowledge, this is the first qualitative study of the PrEP cascade among multiple PPs in Zambia. This study provides important explanation for the low rates of PrEP continuation found in earlier demonstration trials among KPs in Zambia. The study also offers recommendations for programming efforts going forward such as inclusive PrEP awareness campaigns, expanded KP sensitivity training, and related efforts to thwart PrEP stigma while expanding access.

Awareness and Uptake of Pre-Exposure Prophylaxis (PrEP) for HIV Prevention Among Men who have Sex with Men in Nepal

Pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention strategy that remarkably reduces HIV transmission risk. Although PrEP has been available in Nepal since 2019, very little is known about PrEP use among MSM in Nepal. This study aimed to examine PrEP awareness and its use among Nepali MSM and the factors influencing its adoption. A cross-sectional survey was conducted among MSM in Nepal between October and December 2022 (N = 250). Bivariate analysis and logistic regression were performed to determine factors associated with awareness and use of PrEP. In the study population, 59.6% of participants were aware of PrEP, however, only 30.4% of them had utilized it. The odds of PrEP awareness were higher among participants who had completed high school or above (aOR = 4.1; 95% CI = 1.8-9.6), those with health insurance coverage (aOR = 6.9; 95% CI = 2.1-22.3) and had tested for HIV (aOR = 21.2; 95% CI = 8.3-53.9). Similarly, participants who identified as gay (aOR = 3.4; 95% CI = 1.4-8.4), had visited a doctor within the past 6 months (aOR = 2.9; 95% CI = 1.2-6.5), had previously tested for HIV (aOR = 12.3; 95% CI = 3.4-44.7), and had been diagnosed with sexually transmitted infections (aOR = 7.0; 95% CI = 2.5-19.5) were more likely to have used PrEP. Our results highlight the critical importance of healthcare providers engaging in providing care for MSM, including facilitating as well as discussions about PrEP. In addition, there is a pressing need for innovative strategies (e.g., peer educators, social media, online facilitating technologies) to disseminate PrEP knowledge and reduce stigma surrounding PrEP.

The Impact of Human Immunodeficiency Virus on Women in the United States

Substantial improvements have been made in reducing HIV incidence rates among women in the United States. However, numerous disparities affect women's risk of HIV acquisition, in addition to affecting treatment outcomes for women living with HIV. As people with HIV continue to live longer due to antiretroviral therapy, clinicians must be cognizant of various health, financial, and social implications that can affect HIV self-management. Successfully ending the HIV epidemic will require more targeted approaches on prevention, linkage to care, and treatment while also addressing underlying factors that affect women's engagement in HIV-related services across the HIV care continuum.

Perceptions of bias in HIV prevention services, happiness with social support, and anticipated PrEP stigma among Black and Latine/x sexual and gender diverse individuals

Although pre-exposure prophylaxis (PrEP) is a highly effective preventive treatment for HIV, anticipated PrEP stigma can hinder uptake. Perceptions of bias in HIV prevention and evaluations (e.g., happiness) tied to social support among Black and Latine/x sexual and gender diverse (SGD) individuals could be important correlates of anticipated PrEP stigma. To further this line of inquiry, a national sample of 872 Black and Latine/x SGD individuals who had and had never taken PrEP (Mage = 25.1, SD = 2.8) reported how they perceived HIV prevention and how happy they were with their social support. Multivariable linear regressions revealed that greater perceptions of bias in HIV prevention services were associated with higher anticipated PrEP stigma among Black and Latine/x SGD individuals who have never taken PrEP. Greater happiness with friend support was associated with lower PrEP stigma, whereas greater happiness with family support was associated with higher PrEP stigma among individuals who have taken PrEP. Findings highlight the need for PrEP and HIV interventions to address the intersectional stigma attached to prevention and for researchers to understand how evaluations of social support may contribute to stigma among Black and Latine/x SGD individuals.

Structural vulnerabilities and PrEP awareness among Boston heterosexuals and people who inject drugs at risk for HIV: findings from 2018 to 2019 cycles from the Boston, MA site of the NHBS

Little is known about biopsychosocial factors relating to pre-exposure prophylaxis (PrEP) awareness among people with either heterosexual or injection drug use HIV risk behaviors. Participants engaged in vaginal/anal sex with a person of the opposite sex (N = 515) or were people who injected drugs (PWID; N = 451) in the past 12 months from 2018-2019 in Boston, MA. We examined associations between PrEP awareness and: homelessness; perceived HIV-related stigma; country of birth; bacterial STDs, chlamydia, and/or gonorrhea in the past 12 months, lifetime hepatitis C virus (HCV) infection, sexual orientation, and poverty. More PWID (36.8%) were aware of PrEP than people with heterosexual HIV risk (28%; p = .001). Among people with heterosexual risk, homelessness (aOR = 1.99, p = .003), and among PWID: homelessness (aOR = 2.11, p = .032); bacterial STD (aOR = 2.96, p = .012); chlamydia (aOR = 6.14, p = .008); and HCV (aOR = 2.40, p < .001) were associated with increased likelihood of PrEP awareness. In the combined sample: homelessness (aOR = 2.25, p < .001); HCV (aOR = 2.18, p < .001); identifying as homosexual (aOR = 3.71, p = .036); and bisexual (aOR = 1.55, p = .016) were each associated with PrEP awareness. Although having an STD, HCV, identifying as homosexual or bisexual, and experiencing homelessness were associated with increased PrEP awareness, most participants were unaware of PrEP. Efforts to increase PrEP awareness could engage PWID and heterosexual HIV risk behavior.

The Pre-Exposure Prophylaxis Stigma Scale: Measurement Properties of an Adaptation in German and French

Objectives

This study aimed to adapt and validate the HIV PrEP Stigma Scale (HPSS) in French and German languages (HPSS-FR/DE) and assess its applicability across diverse linguistic and cultural contexts.

Methods

The original scale was adapted to French and German and administered through an online survey in multiple European nations. A four-factor structure was extracted from the data, including negative social consequences, social pressure, self-support, and external support. The scale's construct validity, reliability, and cross-linguistic consistency were evaluated.

Results

The adapted HPSS-FR/DE demonstrated robust psychometric properties, good construct validity, acceptable reliability, and consistent measurement across different languages. This adaptation enhances its utility in multicultural settings, offering a comprehensive tool to assess PrEP-related stigma.

Conclusion

This study provides a suitable tool to address PrEP stigma in multicultural environments to enhance PrEP uptake and adherence among men who have sex with men. Moreover, it lays the groundwork for further investigations into PrEP stigma across diverse populations and cultural settings, enabling the development of targeted public health interventions and policies to combat this issue effectively.

Prep-Tok: a queer critical discourse analysis of TikToks regarding HIV-related pre-exposure prophylaxis

Human immunodeficiency virus (HIV) continues to present a public health problem, and pre-exposure prophylaxis (PrEP) offers a promising preventative intervention; however, its uptake remains low, so investigating determinants of use is essential. This article applies queer critical discourse analysis to a corpus of 121 TikToks sampled via the TikTok algorithm, coded and refined into three overarching content categories: 'what makes a PrEP user?', 'what is PrEP as a drug?', and 'sexual health and HIV'. Examples from within these categories reveal four underlying discursive themes: (1) stigmatisation of HIV as a 'gay disease' with a poor prognosis; (2) stigmatisation of gay men as unsafe, high-risk and untrustworthy; (3) stigmatisation of PrEP as increasing 'unsafe' sexual practices; (4) poor healthcare and education gay men and other beneficiaries of PrEP. These themes are influenced by a broad spectrum of homophobic and heteronormative discourses available with specific examples reflecting parts of this spectrum from predominantly perpetuating to occasionally challenging. The findings report complementary evidence obtained from other media platforms yet offer a unique take while suggesting useful avenues for future public health messaging relating to PrEP which may be used to inform the next steps against HIV.

"To do so in a patient-centred way is not particularly lucrative": The effects of neoliberal health care on PrEP implementation and delivery

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention used by HIV-negative people to prevent HIV acquisition. Despite increased use of PrEP worldwide, several barriers to PrEP implementation have resulted in insufficient uptake, inadequate adherence, and frequent discontinuation. Our objective was to interrogate the social, political, and economic conditions shaping PrEP implementation and delivery among gay, bisexual, queer and other men who have sex with men (GBQM) in Ontario, Canada.

METHODS

Six focus groups and three interviews with 20 stakeholders in Ontario (e.g., healthcare professionals, clinicians, community-based organization staff, and government staff) were conducted between July and October 2021. Participants were asked about the personal, workplace, and structural factors shaping PrEP delivery strategies for GBQM. Transcripts were analyzed using reflexive thematic analysis informed by the political economy of PrEP and employed a critique of neoliberalism.

RESULTS

Participants critiqued the problematic arrangements of the current healthcare system in Canada. Neoliberal governmentality and policies have resulted in inequitable PrEP care by establishing funding structures prioritizing profit and requiring patients and providers to function as individual entrepreneurs. Consequently, healthcare disparities are compounded for marginalized peoples who lack the resources and capacity to navigate existing healthcare systems. Participants identified several pathways to improve the implementation of PrEP, including greater institutional and governmental supports for PrEP and healthcare, leveraging communities and collaboration, and moving beyond risk-based health frameworks.

CONCLUSION

Socio-political-economic changes reflecting post-neoliberal principles are needed to overcome existing barriers to PrEP care, and sexual and reproductive healthcare more broadly.

Perspectives on Injectable HIV Pre-Exposure Prophylaxis: A Qualitative Study of Health Care Providers in the United States

The introduction of injectable HIV pre-exposure prophylaxis (PrEP) has the potential to significantly change the biomedical HIV prevention landscape. However, effective implementation will require health care providers to adopt, prescribe, and administer injectable PrEP within clinical settings. This study qualitatively examined challenges and benefit of injectable PrEP implementation from the perspective of health care providers. From April to August 2022, we conducted 19 in-depth interviews with current PrEP-prescribing health care providers in New York State, including 3 physician assistants, 5 physicians, and 11 nurse practitioners. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed to report semantic-level themes regarding injectable PrEP implementation. More than half of participants (61%) were aware of injectable PrEP; only 21% had experience prescribing it. Qualitative findings highlighted five themes. Three themes represented implementation challenges, including speculative concerns about side effects, appointment compliance, and practical and logistical considerations. The remaining two themes described benefits of injectable PrEP relative to oral PrEP, which included greater convenience and enhanced privacy. Findings from this qualitative study make significant applied contributions to the sparse knowledge on health care provider perspectives of injectable PrEP post-US Food and Drug Administration approval and their concerns and considerations regarding implementation in real-world clinical settings.

Acceptability and feasibility of long-term, real-time electronic adherence monitoring of HIV pre-exposure prophylaxis (PrEP) use among young women in Kenya: A mixed methods study

Real-time electronic adherence monitoring involves "smart" pill boxes that record and monitor openings as a proxy for pill taking and may be useful in understanding and supporting PrEP use; however, acceptability and/or feasibility for PrEP users is uncertain. We sought to understand the experiences of using a real-time electronic adherence monitor for PrEP delivery among young women in Kisumu and Thika, Kenya. We used the Wisepill device to monitor PrEP use among 18-24-year-old women for two years. Half of the participants were randomized to also receive SMS adherence reminders (daily or as needed for missed doses). We assessed acceptability quantitatively and qualitatively according to the four constructs of Unified Theory of Acceptance and Use of Technology (UTAUT): performance expectancy, effort expectancy, social influence, and facilitating conditions. We assessed feasibility by monitor functionality during periods of PrEP use. We analyzed quantitative data descriptively and compared by site and over time; qualitative data were analyzed inductively and deductively. The median age was 21 years (IQR 19-22), median education was 12 years (IQR 10-13), 182 (53%) had disclosed PrEP use, and 55 (16%) reported recent intimate partner violence. Most participants reported high levels of usefulness and high interest in using the monitor with few problems or worries reported throughout follow-up. Feasibility was high overall with some differences by site (96% functional monitor days in Kisumu vs 88% in Thika). Few monitors were reported lost (N = 29; 8%) or dysfunctional (N = 11; 3%). In qualitative interviews, electronic monitoring was perceived as useful because it supported privacy, confidentiality, easy storage, and PrEP adherence. Effort was generally considered low. Participants expressed some concern for stigma from monitor and/or PrEP use. Facilitating conditions involved the monitor size, color, and battery life. Overall, real-time electronic adherence monitoring was a highly acceptable and feasible approach to understand PrEP adherence among young women in a sub-Saharan African setting.

Reshaping the narrative: Tracing the historical trajectory of HIV/AIDS, gay men, and public health in Sweden

The human immunodeficiency virus (HIV) emerged as an endemic health crisis in the United States during the early 1980s. Initially labelled a "gay disease" due to its prevalence among gay men, the spread of HIV led to widespread fear and moral panic, as there was limited medical knowledge on preventing its transmission. While HIV is often associated with Sub-Saharan Africa, this article focuses on Sweden, a pioneering nation that became the first to achieve the remarkable Joint UNAIDS/WHO 90-90-90 continuum in addressing the epidemic. However, despite this significant milestone, the punitive legislation and attitudes prevalent in Sweden have had a counterproductive effect on curbing the virus's spread. Drawing upon a comprehensive triangulation of various data and sources on the evolution of public policy in Sweden, this article argues for the urgent need to reduce stigma surrounding HIV and AIDS. By undertaking further measures to combat stigmatisation, we not only have the potential to prevent the spread of HIV but also significantly enhance the quality of life for individuals living with the virus. An essential step in this journey is to eliminate the legally-enforced mandatory disclosure of one's HIV status, which would mark a tremendous victory for all those affected. With limited evidence to support the effectiveness of criminalisation and penal laws, no longer being viewed as criminals for non-disclosure would be a monumental achievement, positively transforming the lives of people living with HIV and fostering a more inclusive and supportive society.

[Daily use of HIV pre-exposure prophylaxis among gay, bisexual and other men who have sex with men in Spain: Prevalence and associated factors]

OBJECTIVE

We aim to estimate the prevalence of daily HIV pre-exposure prophylaxis (PrEP) use 6 months after public funding approval in Spain and identify associated factors in a national sample of gay, bisexual and other men who have sex with men (GBMSM).

MATERIAL AND METHODS

We analysed 4692 HIV-undiagnosed GBMSM men recruited via an online questionnaire distributed nationally via gay contact apps and websites between May and July 2020. We estimated the proportion of participants using daily PrEP and identified associated factors using Poisson regression with robust variance.

RESULTS

Daily PrEP use was reported by 2.8% (95% CI 2.3-3.3) of all participants. Daily PrEP use was independently associated with being recruited into community programmes, being older than 30 years, living in a large city, living with men, having condomless anal intercourse with more than 10 sexual partners, using drugs for sex, especially chemsex drugs, and being diagnosed with a sexually transmitted infection.

CONCLUSION

Six months after PrEP was approved in Spain, the prevalence of daily use is low in a national sample of GBMSM men. There is a need to promote access, demand and interest in PrEP, especially among young GBMSM men, those living in small and medium-sized cities, and those who hide their relationships with other men.

Dimensional Reduction in Barriers and Facilitators to Pre-exposure Prophylaxis (PrEP) Uptake Willingness for Full-Service Sex Workers

Full-Service Sex Workers (FSSWs) face heightened risk of acquiring HIV, yet exhibit relatively low adoption of pre-exposure prophylaxis (PrEP)-an antiviral that substantially reduces HIV acquisition risk. Little work examines barriers and facilitators to PrEP uptake willingness among FSSWs. This study aimed to identify the distinct components of barriers and facilitators to PrEP uptake willingness for FSSWs. Here, we subjected 19 PrEP barriers and facilitators identified in the literature to a principal component analysis (PCA) among a sample of 83 FSSWs. Preliminary statistics supported factorability of data. PCA revealed three distinct components of barriers and facilitators that explained 62.80% of the total variance in survey responses. We labeled these components Behavioral and Social Concerns (α = 0.93), Access and Affordability (α = 0.67), and Biologically Based Health Concerns (α = 0.79). This study shows promise for future clinical and research utility of these factors and provides a basis for future psychometric studies of barriers and facilitators to PrEP uptake willingness among FSSWs.

PrEP initiation and adherence among Black cisgender women in Mississippi: The role of HIV and PrEP stigma and social support

BACKGROUND

Stigma and lack of social support are barriers to HIV prevention, especially among cisgender Black women in the United States. While HIV pre-exposure prophylaxis (PrEP) can decrease HIV transmission, PrEP initiation and adherence remains low among Black women, especially in the U.S. South.

OBJECTIVES

The purpose of this study was to characterize experiences with stigma and social support among PrEP-naïve and PrEP-experienced Black cisgender women in Mississippi.

DESIGN

Qualitative study in which semi-structured interviews and focus groups were conducted.

METHODS

We purposively recruited PrEP-naïve cisgender Black women who met PrEP indications to participate in focus groups and all PrEP-experienced cisgender Black women at a sexual health clinic in Jackson, Mississippi to participate in one-on-one semi-structured interviews. Inductive thematic analysis was used to analyze focus group and interview transcripts.

RESULTS

A total of 37 PrEP-naïve Black cisgender women participated across 6 focus groups and 8 PrEP-experienced cisgender Black women completed semi-structured interviews. Four themes were identified: (1) the intersection of gendered racism, discrimination, and HIV stigma, (2) enacted and anticipated PrEP stigma, (3) stigma mitigation strategies and PrEP adherence, and (4) social support's role in PrEP initiation and adherence. PrEP-naïve and -experienced Black women discussed the negative consequence that sexual stigmatization and gendered racism has on HIV testing. PrEP-naïve Black women discussed how HIV stigma decreases PrEP initiation. Conversely, PrEP-experienced Black women were able to identify strategies they utilized to mitigate stigma. PrEP-experienced Black women discussed how differing levels of social support impact their PrEP use.

CONCLUSION

Improving social support and stigma mitigation strategies could help improve PrEP initiation and adherence among cisgender Black women at-risk of acquiring HIV in the U.S. South. Educating communities on PrEP, and training providers on stigma-mitigating strategies when serving Black women in the U.S. South who are seeking HIV prevention is paramount.

Lived experiences with pre-exposure prophylaxis uptake and adherence among transgender women in Thailand: a qualitative study

BACKGROUND

Transgender women (TGW) are disproportionately affected by HIV, and HIV prevalence among TGW in Thailand has been increasing. Although oral daily pre-exposure prophylaxis (PrEP) is effective for HIV prevention, PrEP uptake and persistence among TGW have been low. This study aimed to provide a deeper understanding of TGW's experiences with PrEP uptake and adherence, and to identify major barriers to PrEP use to inform intervention adaptation.

METHODS

We interviewed 20 young TGW (six non-PrEP users, eight adherent, six non-adherent) and 10 health care providers from two HIV clinics in Bangkok, Thailand, in 2022. We focused on understanding challenges to PrEP use in this population using an interview guide based on a theoretical model of behaviour change and thematic content analysis.

RESULTS

Thematic analysis identified major barriers to and facilitators of PrEP uptake and adherence. Barriers to PrEP initiation included low self-perceived HIV risk, concern about potential side-effects, patient burdens such as frequent HIV testing for prescription refills and social stigma against PrEP. Barriers to adherence included side-effects, inconvenient access to health services (especially during COVID-19 lockdowns), forgetfulness resulting from busy schedules and low self-perceived HIV risk. TGW also reported health care providers' stigma against PrEP users deterred them from seeking further PrEP services. TGW identified major facilitators of PrEP initiation, including awareness about the benefits of PrEP, concern about risks of HIV and supportive social networks of PrEP users. As to PrEP regimens, most TGW participants reported a clear preference for long-lasting, injectable PrEP over daily oral PrEP. TGW and health care providers largely agreed on barriers and facilitators of PrEP use, but they differed in perceptions of HIV risk.

CONCLUSIONS

The results highlighted challenges and opportunities to improve the delivery of PrEP, as well as other sexually transmissable infection and mental health services, especially among TGW. Thus, there is an urgent need for developing effective intervention programs that could raise PrEP awareness and knowledge, reduce PrEP stigma, and improve PrEP delivery systems among TGW in Thailand.

Beyond HIV prevention: Assessment of the benefits of pre-exposure prophylaxis for sexual quality of life

BACKGROUND

Pre-exposure prophylaxis (PrEP) may favor sexual satisfaction by reducing the fear of HIV and promoting less restrictive sexual practices. These benefits may be even higher among PrEP users with mental health issues.

METHODS

We invited adult PrEP users to answer a questionnaire including demographics, questions on the sexual experience compared to the period before PrEP use, and the Hospital Anxiety and Depression Scale. Factors associated with improvements in the sexual experience were investigated using modified Poisson models.

RESULTS

We included 221 participants; most were white males. A large percentage of participants reported improvements in quality of sex after PrEP initiation; the composite outcome "PrEP-associated improvement in the quality of sex" was observed in 92 (42%), whereas the outcome "PrEP-associated improvement in the fear of HIV acquisition" was observed in 120 participants (54%). Demographics and depression/anxiety were not significantly associated with the outcomes.

CONCLUSION

PrEP has positive effects beyond HIV prevention, improving several aspects of sexual quality of life. These benefits are valid incentives for PrEP use and prescription.

"Sex without fear": exploring the psychosocial impact of oral HIV pre-exposure prophylaxis on gay men in England

Gay, bisexual, and other men who have sex with men (GBMSM) experience a high prevalence of psychosocial health problems, such as harmful substance use and depression, as well as being disproportionately affected by HIV. HIV Pre-Exposure Prophylaxis (PrEP) may provide psychosocial benefits beyond its intended purpose of reducing HIV infection. We explore the psychosocial impact of oral PrEP use on gay men in England using qualitative data from the PROUD study. From February 2014 to January 2016, semi-structured in-depth interviews were conducted with 40 gay men and one trans woman. Participants were purposively recruited based on trial arm allocation, adherence, and sexual risk behaviours. By removing HIV risk from sex, PrEP improves users' wellbeing by reducing HIV-related anxiety and internalised stigma and increasing HIV prevention self-efficacy, sexual pleasure, and intimacy. In turn, these psychological changes may influence behaviour in the form of greater sexual freedom, reduced harmful drug use, and more protective sexual health behaviours. However, PrEP may create internal conflict for some gay men, due to its disruption of social norms around condom use and its perceived influence on their sexual behaviour leading to reduced condom self-efficacy. These findings provide a baseline of PrEP's psychosocial impact amongst some of the first PrEP users in England and supports calls to consider the psychosocial impact of PrEP in prescribing guidelines.

'There are people like me who will see that, and it will just wash over them': Black sexual minority men's perspectives on messaging in PrEP visual advertisements

The high incidence of HIV among US Black sexual minority men is a public health crisis that pre-exposure prophylaxis (PrEP) for HIV can help address. Public health campaigns, which often include pictures of Black sexual minority men alongside PrEP-related messaging, have been developed to encourage PrEP awareness and uptake. However, the acceptability of the messaging within these campaigns among Black sexual minority men is unclear. We conducted four focus groups with 18 HIV-negative Black sexual minority men in Washington, DC to explore their perspectives regarding promotional messaging (textual elements) in PrEP visual advertisements, including their reactions to three large-scale public health campaigns. Primary themes included: (1) the need for additional information about PrEP, (2) preference for slogan simplicity, (3) the desire to normalise PrEP use, and (4) mixed views on the inclusion of condoms. Results indicated that the messaging in current PrEP visual advertisements may not sufficiently address Black sexual minority men's questions about PrEP. Providing basic PrEP information and methods to access more information; using simple, unambiguous language; presenting PrEP use in a destigmatising, normalising fashion; and conveying the relevance of condoms if included in the advertisement could help increase the acceptability of future PrEP advertising among Black sexual minority men.

"Protected Means Armed": Perspectives on Pre-Exposure Prophylaxis (PrEP) Among Women Who Engage in Sex Work and Use Drugs in Kazakhstan

Pre-exposure prophylaxis (PrEP) for HIV prevention has recently become available in Kazakhstan, but women engaged in sex work who use drugs (WESW-UD) could benefit from tailored approaches to support uptake and adherence. To better understand how best to support WESW-UD at each stage of the PrEP continuum (awareness, acceptability, uptake, and adherence), we analyzed data from 30 in-depth interviews and four focus groups with 48 WESW-UD from two cities in Kazakhstan. We conducted thematic analysis to characterize perceptions, barriers, and motivators within each step of the PrEP continuum. Participants reported low awareness, but high interest in PrEP. Motivating factors included optimizing health and increased confidence. Participants expressed many preferences and concerns regarding PrEP modality and delivery. Participants also described how organizational mistrust and social support can prevent or facilitate PrEP uptake or adherence. Kazakhstan's scale-up of PrEP should consider the needs and preferences of WESW-UD to ensure equitable access.

Individual and Health System Factors for Uptake of Pre-exposure Prophylaxis Among Young Black and Latino Gay Men

BACKGROUND

Young Black and Latino men who have sex with men (YBLMSM) have the highest rates of new HIV infections in the USA and use PrEP at lower rates than White MSM.

OBJECTIVE

To explore YBLMSM's perspectives and experiences of PrEP use to identify factors enabling or impeding uptake.

DESIGN

Qualitative study using semi-structured interviews conducted between August 2015 and April 2016.

PARTICIPANTS

Black and Latino MSM, 18-20 years of age, who live, socialize, or work in the Bronx, and were fluent in English or Spanish.

APPROACH

We used a thematic analysis to identify themes related to not taking PrEP and PrEP uptake.

KEY RESULTS

Half the participants (n = 9) were currently using PrEP, a majority had Medicaid (n = 13), all reported having a PCP, all identified English as their primary language (n = 15), and all identified as gay. Salient themes included concerns over-side effects, stigma related to HIV and sexuality, mistrust of medical providers, provider's refusal to prescribe PrEP, and insurance and cost.

CONCLUSIONS

Modifiable barriers for PrEP uptake and persistence were reported by most participants, with an emphasis on PrEP misinformation and the pervasiveness of intersectional stigma, providers' low awareness, and hesitant attitudes towards PrEP and barriers created by insurance companies. Supportive infrastructures for PrEP providers and patients are needed.

The Role of Family Support and Communication on PrEP Attitudes and Stigma Among Black Men who Sex with Men (BMSM)

BACKGROUND

This study addresses the gap in the literature on protective factors for preexposure prophylaxis (PrEP) stigma and attitudes among Black men who have sex with men (BMSM) and young adults using the Developmental Assets Framework to examine how external assets (eg, family support, open family communication, and communication with parents about sex and drugs) can help reduce stigma and increase positive attitudes toward PrEP use.

METHODS

A cross-sectional survey was administered to participants (N = 400, mean age = 23.46, standard deviation = 2.59) using Amazon Mechanical Turk, social media sites, and community-based organization. A path analysis was conducted to examine associations between stigma and positive attitudes toward PrEP among external assets (family support, communication with parents about sex and drugs, and open family communication).

RESULTS

Communication with parents about sex and drugs was positive and directly associated with PrEP stigma (β = 0.42, P < 0.001). Family support was negative and indirectly associated with stigma associated with PrEP (β = -0.20, P < 0.001).

CONCLUSIONS

This is the first study to use a developmental asset framework to assess positive PrEP attitudes and stigma among young BMSM. Our results underscore that parents have an influence on human immunodeficiency virus prevention behaviors for BMSM. In addition, their influence can be both positive by helping lowering PrEP stigma and negatively lowering PrEP attitudes. It is critical that we develop culturally competent human immunodeficiency virus and sexuality prevention and intervention programs for BMSM and their families.

Exploring Stigma, Resilience, and Alternative HIV Preventive Service Delivery Among Young Men who Have Sex with Men of Color

Stigmatization on the basis of race, sexuality, gender identity, and/or use of pre-exposure prophylaxis (PrEP) exacerbates HIV disparities for young men who have sex with men of color (YMSM). We explored resilience, healthcare experiences, stigma, and impact of coronavirus disease 2019 (COVID-19) on PrEP care needs among YMSM of color through virtual in-depth interviews. Analyses used adapted grounded theory/constant comparison. Regarding healthcare-based stigma, participants enacted multilevel resilience which was critical to their care retention during COVID-19 (Themes 1 and 2). Some participants noted that remote care could minimize healthcare stigma and promote retention in care and/or on PrEP (Theme 3). Participants were interested in long-acting injectable (LAI) PrEP but expressed concerns about cost, effectiveness, and side effects (Theme 4). Community-based venues like pharmacies were preferred spaces for getting LAI PrEP injections (Theme 4). Although expansion of telehealth that helped mitigate care retention challenges during COVID-19 was temporary, continued telehealth use may reduce stigmatization and promote long-term retention and PrEP persistence.

Effects of mode of transportation on PrEP persistence among urban men who have sex with men

Little is known about the effect of travel-related factors, such as mode of transportation, on retention in PrEP care, or PrEP persistence. We used data from the 2020 American Men's Internet Survey and conducted multilevel logistic regression to estimate the association between mode of transportation used for healthcare access and PrEP persistence among urban gay, bisexual, and other men who have sex with men (MSM) in the U.S. MSM using public transportation were less likely to report PrEP persistence (aOR: 0.51; 95% CI: 0.28-0.95) than MSM using private transportation. There were no significant associations between PrEP persistence and using active transportation (aOR: 0.67; 95% CI: 0.35-1.29) or multimodal transportation (aOR: 0.85; 95% CI: 0.51-1.43) compared to using private transportation. Transportation-related interventions and policies are needed to address structural barriers to accessing PrEP services and to improve PrEP persistence in urban areas.

'We Should Not Be Quiet but We Should Talk': Qualitative Accounts of Community-Based Communication of HIV Pre-Exposure Prophylaxis

Community leaders play an important role in the acceptance of public health services, but little is known about their willingness to facilitate HIV pre-exposure prophylaxis (PrEP) roll-out in Eswatini. We conducted in-depth interviews (n = 25) with purposefully selected male and female community leaders in Eswatini. We analysed our data inductively using a thematic analysis approach. Community leaders feel they are important communicators of culturally appropriate PrEP messaging. Our participants described a complex social space within their communities influenced by religion, tradition, values, and HIV stigma. Community leaders use their position to provide leverage for unique, effective, and easily accessible messages and platforms to reach the community in a manner that ensures trust, relatability, familiarity, and shared faith. Community leaders feel that they are trusted and see trust manifesting in the conversations they are able to engage in, and have a reach that extends beyond formal health services. Existing PrEP programming should embed community leader participation in PrEP programming and engage the trust, knowledge, and potential of community leaders to support PrEP uptake and acceptance.

Perception of PrEP-related stigma in PrEP users: Results from the ANRS-PREVENIR cohort

INTRODUCTION

Since the advent of HIV pre-exposure prophylaxis (PrEP), stigma has been shown to be a major barrier to its uptake and adherence. It is therefore essential to define the proportion of users who consider that PrEP can negatively impact their image and the factors associated with this perception.

METHOD

We performed a multivariable logistic regression on data from the 2567 participants in the ANRS-PREVENIR study who answered the outcome question.

RESULTS

Almost one-third of the sample (comprising mostly cisgender men who have sex with men [94.3%]) considered that taking PrEP could give others a negative image of them. Younger participants (adjusted odds ratio [aOR] 0.98; 95% confidence interval [CI] 0.97-0.99) and more psychologically vulnerable participants (i.e., lower self-esteem score [aOR 0.98; 95% CI 0.96-0.99] and higher depression score [aOR 1.02; 95% CI 1.00-1.03]) were also more likely to have this perception. In contrast, participants encouraged to take PrEP by their main partner (aOR 0.67; 95% CI 0.51-0.88) and friends (aOR 0.79; 95% CI 0.66-0.95), and those who protected themselves more because they had knowledge of their most recent sexual partner's HIV status (aOR 0.83; 95% CI 0.69-0.99) and systematic use of PrEP and/or condoms during intercourse in the previous 3 months (aOR 0.80; 95% CI 0.67-0.96) were less likely to have this perception.

DISCUSSION

Given the strong interrelation between stigmatization (real or perceived), risky behaviours and adherence, our results emphasize the need for HIV prevention campaigns to promote a positive image of PrEP users. They also show that stigmatization and its effects need to be fully considered to improve HIV prevention offers to current and potential PrEP users who are most likely to be psychologically vulnerable.

Experiences of Black Women in the United States Along the PrEP Care Continuum: A Scoping Review

Black women are disproportionately affected by HIV in the U.S. PrEP could decrease the risk of acquiring HIV. This scoping review seeks to understand the experiences of Black women along the PrEP Care Continuum. We searched PubMed, Embase, PsycInfo, and Google Scholar to identify peer-reviewed studies published between July 16, 2012, and December 15, 2021. Articles were included if they discussed PrEP among Black women in the U.S. Two authors screened titles/abstracts and full-text articles. One author extracted and thematically summarized findings (n = 33). Black women reported low levels of PrEP awareness and knowledge, and negative experiences with providers. Women also experienced negative perceptions of PrEP from their social networks, stigma, and mistrust. Future research should focus on helping Black women to overcome PrEP-related barriers. Additionally, future research should further examine barriers to PrEP initiation, adherence, and retention for Black women, as only three studies discussed these aspects of the Continuum.

Cost-effectiveness of the dual prevention pill for contraception and HIV pre-exposure prophylaxis

Introduction

Women in sub-Saharan Africa (SSA) experience the world's highest rates of both HIV infection and unintended pregnancy. The Dual Prevention Pill (DPP) is a novel multipurpose prevention technology (MPT) that co-formulates HIV pre-exposure prophylaxis (PrEP) and combined hormonal oral contraception into a single daily pill. As a dual indication product, the DPP may be preferred by women facing these overlapping health risks. However, most SSA countries face severe healthcare resource constraints. Research is needed to assess whether, in what populations, and in what use cases the DPP would be cost-effective.

Methods

We augmented an agent-based SSA HIV model with maternal health parameters including unintended pregnancy, abortion, and maternal mortality. Based on a previous market analysis, we assumed a primary DPP user population of current oral contraceptive users ages 25-49, and alternative user populations in different risk groups (age 15-24, sex workers, HIV-serodiscordant couples) and baseline product use profiles (unmet need for contraception, oral PrEP use, condom use). In three geographies (western Kenya, Zimbabwe, South Africa), we estimated HIV infections averted, pregnancies averted, disability-adjusted life-years (DALYs) averted, and the incremental cost-effectiveness ratio (ICER) over a 30-year time horizon, assuming equivalent adherence to the DPP as to oral contraceptives, higher adherence, or lower adherence.

Results

The DPP is likely to be a cost-effective alternative to oral PrEP among users in need of contraception. Among women not already using PrEP, the DPP is likely to be cost-saving in sex workers and serodiscordant couples. The DPP is unlikely to be cost-effective in oral contraceptive users in the general population. Switching from oral contraception to the DPP could be net harmful in some settings and populations if it were to substantially reduces adherence to oral contraception. Results were robust to a range of time horizons or discount rates.

Conclusion

The DPP has the potential to be cost-effective and cost-saving in populations at substantial HIV risk. Outcomes are sensitive to adherence, implying that effective counseling and decision-making tools for users considering the DPP will be essential. More research is needed to understand real-life adherence patterns and ensure health benefits achieved from contraception alone are not lost.

Targeted social marketing of PrEP and the stigmatization of black sexual minority men

Disparities in HIV incidence and PrEP uptake suggest a need to prioritize Black sexual minority men (SMM) in PrEP social marketing initiatives. However, images linking Black SMM to HIV and PrEP may inadvertently reinforce stigma. We examined HIV-negative/status-unknown Black SMM's responses to targeted PrEP advertisements using mixed methods, including an experiment embedded in a longitudinal online survey (Time 1: n = 96; Time 2 [eight weeks]: n = 73) and four focus groups (n = 18). The full factorial experiment included between-groups and within-subjects comparisons. For between-groups comparisons, each participant was randomly assigned to view one of 12 advertisements, which varied by couple composition (Black SMM couple/Black heterosexual couple/multiple diverse couples/no couples) and campaign (PrEPare for the Possibilities/PlaySure/PrEP4Love). We examined couple composition, campaign, and interaction effects on: advertisement judgments (Time 1), PrEP stigma (Time 1), PrEP motivation (Times 1 and 2), and PrEP behavior (Time 2). For within-subjects comparisons, each participant viewed all 12 advertisements, and we examined couple composition, campaign, and interaction effects on advertisement judgments (Time 2). Focus group participants discussed advertising preferences and responded to the same set of advertisements. For between-groups and within-subjects comparisons, we found significant couple composition effects but no or limited campaign and interaction effects on advertisement judgments. Advertisements featuring Black SMM exclusively were judged as more stigmatizing than advertisements without couples. Advertisements with diverse (vs. no) couples were considered more eye-catching and motivating. There were minimal effects of couple composition and campaign on PrEP stigma, motivation, and behavior. Focus group participants corroborated concerns about the potential for PrEP advertisements to be stigmatizing, suggesting advertisements featuring Black SMM exclusively could be alienating and fuel conspiracy theories. Focus group participants generally favored diverse and less sexualized advertisements, particularly for public spaces. Findings collectively highlight the potential for targeted PrEP advertisements to stigmatize Black SMM and support diverse representation.

The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities

The effectiveness of HIV pre-exposure prophylaxis (PrEP) hinges on adherence, which has been restricted by multifaceted barriers. Uptake of PrEP has been impeded by poor access resulting from high costs, provider uncertainty, discrimination, stigma, and poor understanding within the health-care community and the public of who can benefit from PrEP. Other important barriers to adherence and persistence over time relate to individuals (eg, depression) and their community, partners, and family (eg, poor support), and their effects vary substantially with each person, population, and setting. Despite these challenges, key opportunities for improving PrEP adherence exist, including novel delivery systems, tailored individual interventions, mobile health and digital health interventions, and long-acting formulations. Objective monitoring strategies will help to improve adherence interventions and alignment of PrEP use with the need for HIV prevention (ie, prevention-effective adherence). The future of PrEP adherence lies in person-centred approaches to service delivery that meet the needs of individuals while creating supportive environments and facilitating health-care access and delivery.

"This Is To Help Me Move Forward": The Role of PrEp in Harnessing Sex Positivity and Empowerment Among Black Sexual Minority Men in the Southern United States

In the United States (U.S.), Black sexual minority men (BSMM) are disproportionately burdened by HIV. Prevention advances, such as HIV pre-exposure prophylaxis (PrEP), play a key role in reducing HIV transmission and improving our understanding of sexual expression and health. Despite these advances, little is known regarding the potential link between PrEP use and positive sexuality, including the benefits that BSMM see in accessing PrEP. We conducted a thematic analysis of 32 interviews with BSMM in the Southern U.S. regarding their PrEP beliefs. We developed five themes: (1) Sexual freedom, (2) Agency and empowerment, (3) Making PrEP normative, (4) Behavioral health practices, and (5) Committed relationship tensions. Our findings suggest that BSMM are increasingly concerned about freedom of choice and invested in sexual empowerment as related to their PrEP use. Further, unanticipated benefits, community support, and relationship tensions are salient factors in considerations of PrEP use among BSMM. These findings have implications for how we might understand a broader movement toward sexual empowerment and positivity, and the pivotal role that PrEP serves in this movement.